1578635066 NPI number — L.A. MEDICAL SUPPLY, INC.

Table of content: (NPI 1578635066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578635066 NPI number — L.A. MEDICAL SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L.A. MEDICAL SUPPLY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578635066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 S HIGHWAY 421 STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40962-7514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-599-9140
Provider Business Mailing Address Fax Number:
606-598-0471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1621 S HIGHWAY 421
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-599-9140
Provider Business Practice Location Address Fax Number:
606-598-0471
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-599-9140

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000001181580 . This is a "CHA PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100202840 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000069793 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 45002821 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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